Environmental Questionnaire and Checklist

U.S. Department of Commerce

National Environmental Policy Act (NEPA)

Environmental Questionnaire & Checklist

Proposed Project Name: ___________________________

Proposing Institution or Entity: ______________________________

Project Description:

(Briefly describe or attach synopsis of proposal):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Amount of Project ($): ___________________________

Contact information for person completing the checklist:

Name: ________________________________________

Phone Number: ________________________________________

Organization: ________________________________________

The Department of Commerce’s (DOC) Administrative Order implementing the National Environmental Policy Act (NEPA) of 1969, (as amended), require environmental data or documentation to assist DOC in carrying out its responsibilities under NEPA. Therefore, it is necessary for the applicant to provide DOC with sufficient information concerning their proposed activity. Based on an environmental evaluation conducted at the project proposal phase, DOC will determine the appropriate level of environmental review. DOC will determine whether an environmental assessment or an environmental impact statement is necessary for the proposed activity or whether the activity can be categorically excluded from additional NEPA review.

Instructions:

The checklist is divided into two sections. Section 1 is for those projects that have historically shown no adverse impacts to the human or natural environment. These projects consist solely of administrative actions, personnel activities, or minor procurement activities. Grants involving the purchase of computers or software going into existing facilities; issuance of fellowships, training or meeting facilitation in existing structures; printing of informational materials or brochures; the hiring of Census takers; and minor interior renovations are suggested to use this section. If the project falls into the one of the categories listed in Section 1, then you do not need to complete Section 2.

Section 2 is for those projects requiring ground disturbance of any kind, building of facilities, installations, or structures; and any project with the potential to significantly impact the human or natural environment.

For Section 2, complete the following checklists based upon your knowledge of the proposed project site and immediate vicinity. If you are “unable to determine” the potential effect on a described resource, efforts should be undertaken to acquire available information on the resource or the effect of the project on the resource. If the proposal is determined to have an effect (checked “yes”) or the preparer is unable to determine if the proposal will have an effect (checked “unable to determine”), the project might be subject to further environmental review, not withstanding other determinations under state environmental review laws and regulations.

If the proposal is determined to have no environmental effect (checked “no”), the project may qualify for a categorical exclusion (CE) from further environmental review. DOC is ultimately responsible for determining if the proposal qualifies for a CE. If all elements of the proposed project do not conform to the identified CE’s (published in the Federal Register on July 10, 2009), an Environmental Assessment (EA) or an Environmental Impact Statement (EIS) may be required prior to funding and/or initiation of the project. Prior environmental reviews may satisfy EA/EIS requirements. Enclose copies of such environmental review reports, including decision documents and evidence of public involvement with this form.

Submit this completed form to:

__________________________________

__________________________________

__________________________________

__________________________________

NOTES:

• Additional sheets may be used to explain responses to specific questions.

• DOC may request additional information.

SECTION 1

To be completed for those projects historically shown to not create significant environmental impacts to the human or natural environment. Any answer of “No” or “Unknown” may require additional documentation or review.

Question	Yes	No	Unknown
1. Is the proposed action solely a procurement action for materials intended to be installed, stored or operated in an existing building or structure?
2. If the proposed action involves procurement of electronic equipment, will the equipment be disposed of in an environmentally sound manner at the end of its’ useful life?
3. Does the proposed action consist solely of personnel actions intended for Census activities?
4. Does the proposed action involve only minor interior renovations to a structure, facility, or installation?
5. Is the proposed action solely for the production and/or distribution of informational materials, brochures, or newsletters?
6. Does the proposed action encompass only literature surveys, inventories, data analysis, or audits?
7. Does the proposed action only involve the granting of fellowships?
8. Does the proposed action consist solely of training, teaching, or meeting facilitation at an existing facility or structure?

SECTION 2

To be completed for those projects involving ground disturbance or potential to significantly impact the human or natural environment. Please answer the following questions:

1. Are the personnel preparing this form familiar with the site?

_____________________________________________

2. List the names of those who conducted the site visit(s):

_____________________________________________

3. List the date(s) of the site visit(s):

_____________________________________________

4. Has consultation with all affected agencies or tribes been completed?

_____________________________________________

5. Provide a description of all the coordination with other agencies and affected Indian tribes incorporated into planning this project and evaluating possible environmental impacts (or attach equivalent information. If none, so state):

Description of agency/tribal contact	Date	Description of attendees/ recipients	Location

6. Provide a description of all the public involvement incorporated into planning this project and evaluating possible environmental impacts (or attach equivalent information. If none, so state):

Name of Event/meeting or public involvement measure	Date	Description of attendees/ recipients	Location

.

7. Please answer all of the questions in the following checklist. If you need additional space to respond, please attach an additional sheet of paper to this document Question	Yes	No	Unable to Determine	Need More Information
Is the proposed project part of a larger scope of work?
If yes, please describe.
Do you anticipate requesting additional federal funding for subsequent phases of this proposed action?
If yes, please describe.
Question	Yes	No	Unable to Determine	Need More Information
Does this proposed action have the potential to be controversial because of disagreement over possible environmental, cultural, or historical resources?
a. If yes, please explain.
Does this proposed action have the potential for significant impact as indicated by a federal, state, or local agency or Indian tribe?
Has any environmental review (e.g., NEPA documentation, permit, historic preservation consultation) been completed for this proposed action?
If yes, please attach a copy of the document to this checklist.
Question	Yes	No	Unable to Determine	Need More Information
6. If the property includes a real estate acquisition or lease, has an Environmental Due Diligence Audit been completed?
a. If yes, please attach a copy of the document to this checklist.
7. Will the proposed action have the potential to impact wetlands, floodplains, coastal zones, or forest conservation areas?
8. Is the proposed action directly related to other actions with individually insignificant, but cumulatively significant, environmental effects?
9. Will the proposed action have uncertain environmental effects?
10. Will the proposed action have the potential to impact species listed or proposed to be listed on the List of Endangered or Threatened Species, or have adverse effects on designated Critical Habitat for these species?
Question	Yes	No	Unable to Determine	Need More Information
11. Will the proposed action establish a precedent for future action or represent a decision in principle about future actions with potentially significant environmental effects?
12. Is the proposed action likely to adversely affect a significant aspect of the natural environment?
Affect the water supplies of humans, animals, or plants;
Affect the water table; or
Involve construction or use of a facility on or near an active geological fault.
13. Does the proposed action contribute to the introduction, continued existence, or spread of non-native invasive species or actions that may promote the introduction, growth or expansion of the range of non-native invasive species (EO 13112)?
14. Does the project involve the generation of ionizing or non-ionizing radiation or use of any radiation source?
Question	Yes	No	Unable to Determine	Need More Information
15. Does the proposed action involve construction on or near an active or abandoned toxic, hazardous or radioactive materials generation, storage, transportation, or disposal site.
a. If yes, will this require new or amended permits or approvals?
16. Will the proposed action involve storage or release of water contaminants (thermal, sediments, oxygen-depleting chemicals, pesticides, fertilizers, substances hazardous to human health, etc.) in amounts greater than allowed in currently existing permits?
17. Will the proposed action involve production, storage, transportation, or disposal of large amounts of solid waste in excess of local waste disposal facility capacity?
18. Will the proposed action involve use of a site that contains underground storage tanks (USTs)?
19. Will the proposed action involve use or release of ozone-depleting chemicals?
20. Will the proposed action involve emission of light or lasers exceeding established standards for persons or animals or affecting surrounding land and airspace uses (such as airports & astronomical observatories)?
Question	Yes	No	Unable to Determine	Need More Information
21. Will the proposed action involve emission of high levels of noise exceeding local noise ordinance levels?
22. Does the proposed action involve the use of sonars or other underwater sound propagation devices?
23. Will the proposed action have disproportionate and adverse effects on the health or environmental risk of different population segments, such as children, the elderly, those with handicapping conditions, low income populations, or minorities?
24. Will the proposed action have an ongoing pattern of pollutant discharge; traffic generation, patterns, or volumes; economic change, or land-use change in its locality that could collectively affect human health or the condition of the environment?
25. Will the proposed action have the potential to affect historic, archeological, or cultural sites, including Native American burial or ceremonial grounds?
26. Will the proposed action involve a known archeological site, or land identified by archeologists as having high potential to contain archeological resources?
Question	Yes	No	Unable to Determine	Need More Information
27. Will the proposed action take place on property under the auspices of the National Capital Planning Commission?
28. Will the proposed action have a disproportionate, significant adverse effect on low-income or minority populations (EO 12898)?
29. Will the proposed action restrict access to and ceremonial use of Indian sacred sites by Indian practitioners or adversely affect the physical integrity of such religious sacred sites (EO 13007)?
30. Will the proposed action have adverse effects on properties listed or eligible for listing on the National Register of Historic Places?
31. Will the proposed action change the use of park lands?
32. Will the proposed action threaten to violate a federal, state, local, or tribal law or requirements imposed for the protection of the environment?
Question	Yes	No	Unable to Determine	Need More Information
33. Will the proposed action require a permit from a federal, state, or local agency to proceed, unless the agency from which the permit is required agrees that a CE is appropriate?
34. Will the proposed action require, in any part, review or permitting by any other federal, state, regional, local, environmental, or regulatory agency?
If yes, please list name of agency and type or review or permit needed.
35. Will the proposed action affect a State's Coastal Zone Management Plan?
36. Will the proposed action violate Occupational Health and Safety Administration (OSHA) standards?

8. Please describe any other aspects of he proposed action that could potentially affect the human or natural environment. Use a separate sheet if necessary.

Certification

(insert Disclaimer and Statute here…)

Project Name: ________________________________________________

Proposing Institution: ________________________________________________

Organizational Entity: ________________________________________________

Signing Official: ________________________________________________

Date: ________________________________________________

OMB Control No. 0660-0031

OMB Control No. 0572-0142

Expiration Date: 01/31/2010

Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act (PRA), unless that collection displays a currently valid Office of Management and Budget (OMB) control number.

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